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Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015 Copyright F.A. Davis © 2015
Chapter 33 Care of the Surgical Patient Modified 2016 by T. Collins, MSN CMSRN
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Purposes of Surgery
Curative: Treats disease or injury
Corrective: Repairs an anatomical or a congenital defect
Cosmetic: Improves physical appearance
Exploratory: Provides further data/diagnosis
Palliative: Alleviates symptoms and provides comfort
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Degree of Urgency
Elective: Voluntary and scheduled a week or more in advance
Urgent: Performed within 24 hours of diagnosis to prevent complications
Emergency: Cannot be delayed
Salvage: Cardiopulmonary resuscitation is in progress or the patient’s life or limb is threatened
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Multiple Choice Question
A nurse schedules surgery to remove a sebaceous cyst from a patient’s leg. This surgery is classified as which of the following?
A. Elective
B. Urgent
C. Emergency
D. Salvage
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Answer
A. Elective
Rationale: Elective surgery is any surgery that is voluntary and scheduled a week or more in advance. Elective surgery includes those surgeries intended to improve a patient’s quality of life, either physically or psychologically. The surgery may be medically necessary, such as a cyst removal, or may be patient-desired, such as breast augmentation.
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Various Surgical Settings
Outpatient
Stand-alone surgery center
Medical office
Hospital outpatient surgery department
Inpatient
Hospital-based surgery
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Preoperative Care of the Surgical Patient
Components of the Pre-surgical Assessment
Patient history
Review of all body systems
Physical exam
Laboratory testing
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Preoperative Diagnostic Testing A minimum of:
CBC, UA, EKG
Commonly done:
Bleeding indicators: PT, INR, aPTT
Nutritional status: prealbumin, albumin, transferrin, total protein
Glucose, electrolytes, BUN, creatinine, GFR, bilirubin, SGOT, SGTP, amylase, alkaline phosphatase, uric acid, cholesterol
Radiology: CXR
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Preoperative Patient Teaching When should preop teaching beginning?
Provides a smoother, shorter recovery period
Decreases anxiety, increases compliance
TCDB exercises
Incentive spirometry
Leg/feet exercises
SCDs, TED hose
Pain and nausea relief measures
Medications
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Preoperative Medications Purposes:
Relief of apprehension and anxiety
Sedation
Analgesia
Amnesia
Decrease of anesthetic requirements
Decrease of gastric volume and acidity
Prevention of nausea and vomiting
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Purposes of Preoperative Medications (cont.)
Dry secretions and prevent aspiration
Prevent bradycardia
Facilitate induction
Decrease risk of allergic reaction
Decrease stress of parental separation
Prevent infection
Prevent clot formation
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
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Informed Consent
Physician
Explain procedure, available alternatives, and risks of the procedure and anesthesia
Nurse
Make sure the consent form lists correct surgical procedure and is signed by the patient and the physician
Answer patient questions and concerns
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Preoperative Checklist Provides confirmation that all pre-op tasks have
been completed and that the patient is ready for surgery
Usually placed on front of chart for OR staff convenience
Also provides documentation
Confirms the presence of Consent, Hx & Px, and lab results in chart AND ID band, prep, NPO status, location of prosthetics, allergies, and pre-op VS and meds.
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Intraoperative Care of Surgical Patient
Surgical Team Members:
Anesthesia provider
Surgeon
First surgical assistant
Circulating nurse
Scrub nurse
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Multiple Choice Question
Which of the following is the scrub nurse’s main task?
A. Coordinating the surgical team
B. Providing and maintaining a sterile field
C. Being the primary patient advocate
D. Sustaining the patient’s life
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Answer
B. Providing and maintaining a sterile field
Rationale: It is the scrub nurse’s job to set up the sterile field immediately prior to beginning the procedure. It is also the scrub nurse’s responsibility to see that field sterility is maintained while she actively assists the surgeons working within the sterile field during surgery.
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Types of Anesthesia General anesthesia: The patient is totally
unconscious; must be intubated
Conscious sedation: The patient is asleep but not totally unconscious; can breath on his own
Regional anesthesia: Specific nerves and the region innervated by the nerves are blocked from sensory perception
Local anesthesia: A very small area of tissue is blocked from sensory perception
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Basis for the Selection of Anesthesia Type
Type of surgery to be performed
Length of time the surgery will take
Patient’s preexisting medical conditions
Any reactions to previous anesthesia
Preference of the surgeon and the anesthesia provider
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Intraoperative Interventions Intubation and suctioning
Miscellaneous interventions and equipment
Positioning patient
Surgical shave
Surgical scrub
Draping the patient
Tissue specimens
Needle, sponge, and instrument counts
Final intraoperative interventions
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
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Intubation vs Extubation
Intubation
Insertion of an endotracheal tube into the patient’s trachea to maintain an open airway and ventilate the patient
Used to deliver inhaled anesthesia
Extubation
Removal of the endotracheal tube
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
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Surgical Procedures
Suffixes/Words:
– ectomy: to remove
– otomy: to cut or separate
– ostomy: to create an opening
– ablation: to remove from
transplant: to uproot and replant
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Postoperative Care of the Surgical Patient
1. Maintain airway and gas exchange: R, SpO2, and breath sounds; assess skin color; provide suction PRN
2. Monitor cardiac function: BP, AP, peripheral pulses, skin temp
3. VS every 5-15 minutes as determined by condition
4. Monitor level of responsiveness
5. Monitor surgical site and drains
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
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Postoperative Care of the Surgical Patient (cont.)
6. Administer IV fluids
7. Equipment: telemetry, O2, Foley catheter, NG, PCA, etc.
8. Assess and medicate pain, nausea, and other discomforts
9. Safety interventions
10. Documentation
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Return to the Patient’s Room Room Preparation:
Must be ready before the patient returns from recovery!
Make the post-surgical bed
Arrange furniture to accommodate the gurney
Provide the following:
Suction supplies
O2 supplies, IV pole, and pump
VS equipment, penlight
Emesis basin/bag
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Preparation of the Hospital Room (cont.)
Washcloths/towels/clean gown
Blankets and extra pillows for positioning
Mouth care supplies, lip lubricant, tissues
TEDs, SCDs
Ice chips, if allowed
Bedpan and calibrated measuring device to measure urine
Pen and paper for notes
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Initial Post-Op Assessment
First Priority: Open airway and gas exchange, respirations, skin color, SpO2, apply O2 if needed
Second Priority: LOC, BP, and radial pulse; auscultate breath sounds, AP, and bowel sounds; assess pupils and peripheral pulses
Surgical Site: Assess bleeding and drainage; assess for abd distention
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Post-Op Assessment Priorities (con’t.)
IV fluids
Foley or assess for bladder distention
Assess for pain, nausea, and discomforts
Safety interventions
Documentation
Physician’s orders
Then assess VS according to the patient’s condition and the facility’s policy for frequency
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Postoperative Problems and Complications
Respiratory: Airway obstruction, hypoxemia, hypoventilation, atelectasis, pulmonary embolism, pneumonia
Cardiovascular: Tachycardia and other
arrhythmias, ↓BP, ↑BP, decreased cardiac output, DVT
Hemorrhage
Gastrointestinal: N/V, paralytic ileus
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Postoperative Problems and Complications (cont.)
Hypothermia or fever
Pain and discomfort
Urinary retention
Wound infection
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Wound Infections Approximation
Edges of the surgical incision meet and are aligned with each other
Dehiscence Separation of the wound edge
Seen in approximately 2% of all midline abdominal incisions
Associated with 15% to 40% mortality
Caused by infection
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Information in the Connection Features
Clinical Connection
Knowledge
Laboratory and Diagnostic
Patient Teaching
Real World
Supervision/Delegation
Post Conference
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Information in the Safety Features
Why are the particular safety features so important that they are highlighted as safety issues?
What could happen if those safety guidelines are not followed?
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Information in the Skills Procedures
Review the steps of each of the skills procedures.
Make sure you understand why the steps are important.
What could happen if each of the steps are not followed or are followed out of order?
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